1962952655 NPI number — PORTLAND GASTROENTEROLOGY EQUIPMENT

Table of content: (NPI 1962952655)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962952655 NPI number — PORTLAND GASTROENTEROLOGY EQUIPMENT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PORTLAND GASTROENTEROLOGY EQUIPMENT
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
THE OREGON CLINIC ENDOSCOPY CENTER - EAST
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1962952655
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/26/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
541 NE 20TH AVE STE 225
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORTLAND
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97232-2895
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-963-2801
Provider Business Mailing Address Fax Number:
503-963-2825

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1111 NE 99TH AVE STE 302
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97220-9442
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-963-2760
Provider Business Practice Location Address Fax Number:
503-963-2783
Provider Enumeration Date:
10/06/2016

Additional Information

Authorized Official

Authorized Official Last Name:
JAMISON
Authorized Official First Name:
RICHARD
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
503-963-2801

Provider Taxonomy Codes

  • Taxonomy code: 261QE0800X , with the licence number:  07-1535 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 500719790 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".




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